PSYC 335 University of Maryland Wk 7 The Future of Personality Discussion

SOLUTION AT Academic Writers Bay

HIMA 250 1002 American Military University WK6 Organization Health Record Documentation Policy Worksheet

HIMA 250 1002 American Military University WK6 Organization Health Record Documentation Policy Worksheet
Instructions ASSIGNMENT: Create Health Information Documentation Guidelines CAHIIM Competency: Subdomain I.B. Health Record Content and Documentation Compile organization-wide health record documentation guidelines Scenario: You are the new HIM Director for Community Healthcare which includes an acute care hospital, an attached clinic and an attached long term health facility. After several weeks on the job you realize that the documentation guidelines are outdated and it appears they have not been updated for nearly 10 years. After asking questions of the staff, it sounds like they are following current documentation standards, it is just that the written guidelines have not been brought up to date. You set out to update the written guidelines. You first need to compile the guidelines set forth by Joint Commission and CMS since those are the regulatory bodies that monitor your organization. Instructions: Locate the documentation standards for the Joint Commission and CMS and Conditions of Participation. Create a table listing medical record documentation standards for both the Joint Commission and CMS Conditions of Participation for each segment of Community Healthcare (Acute Care Hospital, Clinic, and Longterm Care). You will have 3 tables, one for each type of facility. Title the document as a policy and write a short explanation of the purpose of the document and how it should be used. ASSIGNMENT: Secondary Data Sources CAHIIM Competency: Subdomain I.E. Secondary Data Sources Validate data from secondary sources to include in the patient’s record, including personal health records Preparation: Read the Processing and Maintenance of Secondary Databases section of Chapter 6 in the Oachs and Watters text. (Page 191-193 in the 5th edition)While the reading focusses on data from patient health records being abstracted or moving electronically into secondary data source systems, more and more we are having to consider data from secondary data sources being used to add to the primary health record. Examples: A patient brings in their personal health record that contains health information from 2 other primary care providers at local clinics. They want this information added to their health record at your hospital. Inbound HIE data from an earlier encounter from an unrelated provider is electronically received for a patient’s health records Inbound data from the patient portal is received many times a day as patients update their demographic or insurance information on the patient portal Data is received from smart devices such as ambulatory heart monitors or insulin monitors and is downloaded into patient records It would be inefficient for all of this inpatient data to be manually checked for validity. Please describe in 2-3 paragraphs (400-500 words) how a healthcare organization could assure that this incoming data is valid and accurate. Be sure to specifically address how systems would be set up, as well as standards and policies that would need to be set.

Diabetes Hypertension & Cardiovascular Disease and Vascular Mechanisms Discussion

Diabetes Hypertension & Cardiovascular Disease and Vascular Mechanisms Discussion
IntroductionFor this assessment and others in this course, you will assume the role of an office manager for a physician group. In most fields, whether manufacturing, the service industry, or health care, organizations are looking for ways to improve the quality of service they provide to their customers. An eye on quality helps them remain competitive in the marketplace and stay in business. Otherwise, their customers will go elsewhere. This is especially true in the health care field where people’s health and lives are at stake.Demonstration of ProficiencyBy successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:Competency 1: Outline the steps of the health care information life cycle.Apply steps of the health care information life cycle.Competency 2: Apply laws governing health information confidentiality, privacy, and security. Differentiate between required confidentiality and security measures.Apply laws governing health information confidentiality, privacy, and security.Competency 3: Assess system applications used to operationalize health information.Evaluate which information system or systems best provide needed information.Competency 6: Communicate in a manner that is scholarly, professional, and respectful of the diversity, dignity, and integrity of others, and consistent with the expectations for health care professionals.Write clearly with correct spelling, grammar, and syntax, and good organization.Apply proper APA formatting and style to references and citations.PreparationYour physician group is no different than other organizations. It wants to find ways to improve the quality of care it provides to patients. This, in turn, helps the physician group remain profitable and stay in business. As a result, the senior leaders of your physician group have asked you to provide a documentation review of the quality of care provided by the office. As the office manager, you are the one responsible for the management of the health information within the office and the review of information to determine whether providers met quality of care standards. Determining this will require you to:Identify a disease or condition served by the physician group.Determine what patient information is needed and from where to retrieve it.Compare your overall office data to the national benchmarks.Typically, in the workplace, the physician group’s specialty area (cancer, diabetes, dermatology, et cetera) would dictate the disease or condition for which you would be collecting information. For the purpose of this assessment, however, you may select the disease or condition that interests you from this list:Asthma.Diabetes.Myocardial infarction.HIV/AIDS.Cancer.Select the disease or condition that is important to you and that you want to study. Perhaps, you have the disease or condition. Perhaps, a family member or friend does. Remember you will be working with this condition in the remaining course assessments. Now that you have determined the disease or condition you are going to study, you will need to begin collecting protected health information (PHI) for the patients treated by your physician group who have the condition you are studying. You will need to consider carefully the privacy, security, and confidentiality of the information within the patients’ office records. Determining how you as the office manager will maintain data security is a key aspect of your work. You are responsible for knowing and understanding the types of documentation, applications, and information systems used within and outside of the office. All information moves through a life cycle from creation to destruction. Regulations, policies, and procedures strictly control this ongoing process. The office manager needs to know this life cycle and where to locate information when it is needed.For this assessment, you will write a section of a proposal about how the documentation on previous patient care will be retrieved, from where it will be retrieved, and how that data will be kept secure during retrieval and review. Remember that you are focusing on retrieving and analyzing existing documentation within the office.For this section of your proposal:Identify the disease or condition and the population that will be the focus of your study.Explain your plan to manage this information from collection to storage to destruction.Identify legal considerations and a plan for compliance for the PHI you are collecting.In later assessments in this course, you will continue on with your proposal and begin to plan for how you will compare the office data you have collected to the national benchmarks. Remember: You will not be able to actually do this comparison. You are simply preparing a proposal for senior leaders about how you would go about performing this work.Please read the scoring guide for this assessment to better understand the performance levels relating to each criterion on which you will be evaluated.InstructionsYou will not be writing the entire proposal for this assessment, only parts of it. You will add to your proposal in later assessments and complete it in Assessment 3. Be sure this part of your proposal includes all of the following headings, and your narrative addresses each of the bullet points:IntroductionIdentify the disease or condition from the following list for which you will review the quality of care:Asthma.Diabetes.Myocardial infarction.HIV/AIDS.Cancer.Explain the reasons for your choice.Information CollectionComplete the following:Determine the patient population to be reviewed.Evaluate which information system or systems best provide the needed information.Determine the specific documentation you are looking for. Explicitly state the reasons for each and all of your choices. Be sure to answer all of the following questions in your narrative:Do you want to review information only from your office? Or do you also want to review information for hospital admission and/or emergency room visits?Do you wish to review all patients who have ever been treated for the selected condition? Or only those treated within a specific time frame? Will you only review patients within certain demographic parameters?What type of documentation do you want to review? This may include:History and physical (H&P).Discharge summary.Progress notes.Labs.Radiology.Others.Identify where you are going to find the information you need. Which information system or systems would be best to use, and what information can you collect from each system? Possibilities include:Pharmacy.Point of care (POC).Results management.Computerized physician order entry (CPOE).Determine the type of system or systems (financial, administrative, clinical, et cetera) you would use.Information Life CycleComplete the following:Describe how you plan to manage this information from collection to destruction. Be sure to address all of these questions in your narrative:How will the information be collected and documented? By whom? In what context?How will the information be stored?How will you control access to the information?How can you ensure the documentation meets interoperability standards?What are the advantages and disadvantages of integrating your office information with an HIE? What challenges exist regarding the standardization of health information?When and how will the information be destroyed?Legal ConsiderationsComplete the following:Differentiate between the legal aspects of health information confidentiality, privacy, and security, as it applies to your proposal.Apply laws governing health information confidentiality, privacy, and security.Determine whether the information you are retrieving requires the use of PHI.If not, why not?If so, summarize how the PHI will be used.Plan for how the Health Insurance Portability and Accountability Act (HIPAA) will impact health care personnel, policies, and procedures in your proposal.ConclusionBriefly summarize the value of the documentation review you are proposing to be performed.Additional RequirementsYour assessment should meet the following requirements:Written communication: Your paper does not need to be in APA format. It does need to be clear and well organized, with correct spelling, grammar, and syntax, to support orderly exposition of content.Title page: Develop a descriptive title of approximately 5–15 words. It should stir interest yet maintain professional decorum.References: Include a minimum of two citations of peer-reviewed sources in APA format.Length: 3–5 typed, double-spaced pages, not including the title page and references page.Font and font size: Times New Roman, 12 point.SCORING GUIDEUse the scoring guide to understand how your assessment will be evaluated.VIEW SCORING GUIDECRITERIANON-PERFORMANCEBASICPROFICIENTDISTINGUISHEDDifferentiate between required confidentiality and security measures.Does not differentiate between required confidentiality and security measures.Makes some differentiation between required confidentiality and security measures, but there are significant errors or omissions.Differentiates between required confidentiality and security measures.Develops cogent and explicit criteria to differentiate between required confidentiality and security measures.Apply laws governing health information confidentiality, privacy, and security.Does not identify some laws governing health information confidentiality, privacy, and security that need to be applied to a proposal.Identifies some laws governing health information confidentiality, privacy, and security that need to be applied to a proposal, but there are significant errors or omissions.Applies laws governing health information confidentiality, privacy, and security.Applies laws governing health information confidentiality, privacy, and security, and explicitly describes required policies and procedures.Evaluate which information system or systems best provide needed information.Does not identify any information systems that can provide needed information.Identifies an information system or systems that can provide needed information.Evaluates which information system or systems best provide needed information.Develops cogent and explicit criteria to evaluate which information system or systems best provide needed information.Apply steps of the health care information life cycle.Does not identify steps required in the health care information life cycle.Identifies steps required in the health care information life cycle, but there are significant errors or omissions.Applies steps of the health care information life cycle.Concisely details efficient procedures for management of an information life cycle, including the systems and procedures for collection, documentation that meets standards for interoperability, integration into a HIE, storage, control of access, and destruction.Write clearly, with correct spelling, grammar, and syntax, and good organization.Does not write clearly, and there are errors in spelling, grammar, syntax, and organization.Writes clearly overall, but there are some errors in spelling, grammar, syntax, or organization.Writes clearly, with correct spelling, grammar, and syntax, and good organization.Writes concisely, with excellent clarity and organization, with no errors in spelling, grammar, or syntax, and employing critical or analytical reasoning as needed.Apply proper APA formatting and style to references and citations.Does not apply proper APA formatting and style to references and citations.Applies APA formatting and style to references and citations inconsistently and with significant errors.Applies proper APA formatting and style to references and citations.Consistently applies proper APA formatting and style to references and citations without errors.

CLICK HERE TO GET A PROFESSIONAL WRITER TO WORK ON THIS PAPER AND OTHER SIMILAR PAPERS

CLICK THE BUTTON TO MAKE YOUR ORDER

error: Content is protected !!